The promise of reducing cost for vascular procedures by making some of them available in an outpatient setting hasn't come to fruition. While more patients are indeed having catheter-based procedures to remove plaque from their arteries without hospital stays, the procedures being employed are sometimes pricier than they're worth.

That's according to a group of surgeons with the Michigan Medicine Frankel Cardiovascular Center and the Department of Surgery, who say higher reimbursement rates for performing atherectomies may be incentivizing too many surgeons to select them over other options like balloon angioplasty and stenting.

"We reviewed the data, and did not find evidence that atherectomy leads to better outcomes than more affordable options like angioplasty," says lead author Craig Brown, M.D., a resident surgeon at Michigan Medicine. Atherectomy was actually associated with a higher risk of some adverse events including amputation.

"We've been working with Blue Cross Blue Shield of Michigan to improve the care of patients with vascular disease in Michigan, and these data will inform evidence-based practice change," Brown says.

Notably, the authors report that only 10% of providers across the state performed 70% of the atherectomies, accounting for nearly 85% of total payments.

"We are very fortunate to have a close and collaborative partnership among Blue Cross Blue Shield of Michigan, Michigan Medicine and the vascular surgeons across the state. As a result, I am optimistic we can improve care," says study author Michael Englesbe, M.D., a professor of surgery.

To address these issues and maximize vascular surgery value, the authors report steps they're taking across Michigan through a partnership with Blue Cross Blue Shield of Michigan, including:

• Develop a care pathway for peripheral arterial disease with a focus on atherectomy, then leverage value-based reimbursement incentives to motivate its implementation.

• Set statewide benchmarks for the ratio of atherectomy to stenting and balloon angioplasty.

• Leverage claims data to identify frequent atherectomy users and set up educational meetings with them.

• Even the playing field by increasing reimbursement for stenting and balloon angioplasty, while reducing reimbursement for atherectomy.

Authors Ryan Eton, M.D., Matthew Corriere, M.D., Englesbe and Nicholas Osborne, M.D., M.Sc., are members of the University of Michigan's Institute for Healthcare Policy & Innovation. Peter Henke, M.D., interim head of vascular surgery, also served as a co-author. The Michigan Quality Collaboratives, including the Michigan Value Collaborative, are made possible through support from BCBSM.

Paper cited: "Using Payment Incentives to Decrease Atherectomy Overutilization," Annals of Vascular Surgery. DOI: 10.1016/j.avsg.2021.01.061